Posted : 12/07/2012
When the Duchess of Cambridge checked into the King Edward VII Hospital in London with a nasty bout of morning sickness, she didn't have to worry about such common matters as health insurance deductibles, emergency room copayments or whether a claims examiner might balk at the three-night stay.
When one is carrying a British heir to the throne, after all, one is entitled to health care fit for a king.
For you though, royal treatment isn't likely, even if you have good health insurance. Here are some of the things Her Royal Highness, the former Kate Middleton, doesn't have to ponder in pregnancy -- but you should:
Most individual health insurance plans -- the kind you buy yourself, rather than get through an employer -- do not cover pregnancy and maternity care. Nationwide just 13 percent of individual health plans available to a 30-year-old woman provided maternity benefits in 2009, according to the most recent figures from the National Women's Law Center.
That will change in 2014 when individual and small-group health plans will have to provide maternity coverage, along with other so-called "essential health benefits." Moreover, insurers in 2014 won't be allowed to deny coverage or charge higher premiums for people with illnesses or existing health conditions, including pregnancy. (See: "Health reform sticks: Now what?")
Until then, if you don't have access to employer-sponsored coverage, either through your job or a spouse's employment, check whether you qualify for Medicaid, the national and state health insurance program for low-income individuals, or a Pre-Existing Condition Insurance Plan (PCIP), established under the Patient Protection and Affordable Care Act. To qualify for the PCIP, you have to have been uninsured for at least six months, and you have to pay the premiums yourself.
Most job-based health plans cover pregnancy and maternity care. That's because the Pregnancy Discrimination Act of 1978, which applies to employers with at least 15 workers, requires these plans to cover pregnancy just like they cover other medical conditions. (See: "5 things you don't know about group health insurance.")
However, the law doesn't require those plans to extend maternity benefits to dependent children. Under the Affordable Care Act, young adults now can stay on their parents' job-based health plans up to age 26, even if they live away from home or are married. An estimated 1.1 million young women have health insurance coverage as a result of the provision, according to a U.S. Department of Health and Human Services research brief.
If you're among them, check to see if your parent's plan extends maternity benefits to you.
New health plans or ones that have been changed substantially since the Affordable Care Act was passed in March 2010 must cover preventive care, including a list of services geared to women, without charging a deductible, copay or co-insurance.
Among the "free" services for pregnant or nursing women:
You also can go to an obstetrician or gynecologist without a referral.
However, "grandfathered" health plans don't have to fully cover preventive care. Grandfathered plans are those that were launched before the health care reform law was passed and have stayed essentially the same. Almost half, 48 percent, of people with job-based health insurance are in grandfathered plans this year, according to a Kaiser Family Foundation survey. Some grandfathered plans still provide fully covered preventive care even if though they're not required to, but some don't.
But state or federal law could guarantee you only a couple of days in the hospital after giving birth. Under the federal Newborns' and Mothers' Health Protection Act of 1996, self-insured group plans can't restrict hospital stays for childbirth to less than 48 hours after a vaginal delivery or 96 hours after delivery by cesarean section. Most very large employers are self-insured -- they bear the risk and pay claims directly.
Many states have enacted similar laws which apply to health plans under which insurance companies pay the claims. Unless you have royal connections, check your health plan to see what coverage you have for pregnancy and maternity care -- preferably before you get pregnant.
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